Chapter 1: Bruises and Other Skin Injuries

Distinguishing between intentional and unintentional bruises and skin injuries must be undertaken with knowledge of pattern injuries that should trigger suspicion. Medical personnel must be aware of all key indicators of physical abuse when determining the cause of skin injuries by comparing their patterns and locations and the initial history given by caregivers.

Chapter 2: Burns

Once treatment has been given for children's burns, efforts can be directed toward obtaining an accurate history of the injury. Investigators must carefully outline the time, nature, extent, and location where the burn occurred based on information they have gathered from witnesses, family members, and medical personnel. Therefore, medical personnel must note the exact shape, depth, and margins of all wounds, including all body parts involved. Immediate attention to these details can prove to be invaluable when drawing a later distinction between an abusive and accidental injury.

Chapter 3: Head Injuries NEW CHAPTER!

Abusive head injury frequently results in serious and permanent brain damage. The forces generated on the infant's brain are severe. Medical professionals must consider each injury individually since they involve the internal layers of tissue as well as those surrounding the brain. While this is a logical approach to describing the injuries, most cases of abusive head injury involve multiple injuries occurring throughout the infant's body.

Chapter 4: Thoracoabdominal NEW CHAPTER!

Thoracoabdominal trauma is the second leading cause of traumatic death in child abuse. This trauma may be seen by itself, but it is often seen in the context of other injuries. It is therefore important to screen for abdominal trauma, even if not readily suspected. A number of children with shaken baby syndrome have suffered abdominal trauma with no visible manifestations, and were therefore left untreated.

Chapter 5: Oral Injuries

Oral injuries in child abuse include trauma to the teeth, supporting structures, and surrounding oral tissues. Abusive acts may include commission, such as actively striking children in the mouth, or omission, such as neglecting to seek necessary dental care. As mandated reporters, dentists must learn to recognize the indicators of orofacial abuse and the proper ways in which to document and report abuse. Bite marks on a child are pathognomonic for abuse. Dentists often create impressions based on the bite marks on a child in order to aid in the determination of the perpetrator.

Chapter 6: Ophthalmology

Presenting signs of child abuse involve the eyes are most often associated with ophthalmic manifestations of child abuse is shaken baby syndrome. Retinal hemorrhages result from shaking and can be subretinal, intra-retinal, predominantly in the bipolar layer, or in the nerve fiber layer. Some nonabusive conditions or injuries may manifest ocular injuries, including: periorbital edema and subconjunctival hemorrhage, injuries occurring during the birth process, and injuries sustained when cardiopulmonary resuscitation has been administered.

Chapter 7: Radiology

Any bone can be broken as the result of child abuse. While there are certain fractures that are highly specific for the diagnosis of child abuse, any bone broken without adequate explanation must be considered as possible child abuse. Although it is true that abusers may sometimes break more than one bone of a child, the most common number of fractures in an abuse case is one.

SECTION II. SEXUAL ABUSE

Chapter 8: Sexual Abuse

Although three fourths of the crimes against children are sex crimes, 60% to 70% of children claiming to be abused do not show physical findings of sexual abuse during their medical examination. Several physical findings, such as pregnancy, STDs, and semen in the vagina in a child under 12 years of age, will clearly diagnose abuse. However, without a credible statement from the child identifying the perpetrator, the investigation can be thwarted.

SECTION III. NEGLECT

Chapter 9: Neglect

Issues of neglect, including physical, emotional, educational, supervisory, and nutritional neglect, are often overlooked and under-investigated. These forms of neglect may lead to a failure to gain weight and failure to thrive, which involves not only inadequate weight gain but also developmental and behavioral disturbances. Medical and dental neglect can contribute to even more significant health problems, and can lead to morbidity and potentially death.

Chapter 10: Munchausen Syndrome by Proxy NEW CHAPTER!

Munchausen syndrome by proxy occurs when a caregiver makes a false claim about and/or generates a false symptom or sign of a medical illness in a child. This is not only medical abuse and neglect because inappropriate medical care is sought, but also physical abuse because medical interventions, such as unnecessary examinations and tests, are performed. These caregivers administer prescription medications as well as laxatives, vitamins and minerals, alcohol, automotive products and basic substances to children to falsify or exaggerate illness.

SECTION IV. EVALUATION, EQUIPMENT, AND DEMONSTRATIONS

Chapter 11: Photodocumentation NEW CHAPTER!

If at all possible, significant visible findings must be photographed. The ability to take high-quality, representative pictures of visible findings is an essential skill for anyone evaluating and interpreting physical and sexual abuse findings for legal purposes and for teaching and peer review. For courtroom purposes, high-quality photographs act as an illustration to help the examiner convey the findings of the case.

Chapter 12: Documentation of Physical Abuse NEW CHAPTER!

Documentation of physical abuse is necessary for several purposes. Primarily, it enables further reflection on an examination long after it has been completed. Documentation can also involve the measurement of physical dimensions, quantities, and qualities in a manner that might be reproducible or more understandable. Thus a fall off a bed may invoke a mental image of the likely height, but measurement removes the guesswork.

Chapter 13: Sexual Abuse Documentation NEW CHAPTER!

When allegations of sexual abuse are assessed, the implications are profound for the child, alleged offender, and their respective families, as well as for the evaluator. Accurate recording of information obtained is critical. It is common for court proceedings regarding sexual abuse allegations to take place months or even years after allegations were initially presented and evaluated. As a result, detailed written and/or taped documentations regarding evaluation procedures, including statements made by the child, caregiver, alleged offender, and collateral sources, are of utmost importance.

Chapter 14: Documentation of Neglect NEW CHAPTER!

Neglect is the most common type of child abuse documented by child protective services. Unlike physical and sexual abuse, neglect does not typically occur as a discrete episode. Instead, it is chronic and pervasive. Injuries from neglect tend to be developmental and emotional, and as a result, are harder to document and diagnose. Growth is one of the physical signs of neglect and is more commonly documented visually. While failure to thrive due to neglect means far more than failure to grow, growth can be an excellent indicator of maltreatment.

Chapter 15: Computer and Other Demonstrations NEW CHAPTER!

Demonstrations are useful in a variety of contexts in which words do not convey information as well as a visual demonstration. They can be helpful in teaching students, and even professionals, who are not knowledgeable about child abuse issues. Demonstrations may also be useful in the courtroom. Such demonstrative aids help to inform the judge and jury of the types of injuries involved in the case.

SECTION V. INVESTIGATIONS

Chapter 16: Medical Examiner

Medical examiners play several roles in the evaluation of a patient's death. With regard to cases of suspected child abuse and neglect, they are asked to determine the cause and manner of death to a reasonable degree of medical certainty; provide expert evaluation of the presence, absence, nature, and significance of injuries and disease; collect and preserve evidence; correlate clinical and pathological findings; and present expert opinions and testimony in appropriate forums.

Chapter 17: Police Investigations

The role of the police in child maltreatment cases is first to determine if a crime has been committed and then to gather evidence regarding that crime. When a child is hurt, the police work most effectively with medical personnel and child protection workers in determining if the injury is deliberate, accidental, or the result of a natural disease process. In cases of suspected child abuse, the police investigator interviews potential suspects and witnesses, conducts scene examinations, and collects evidence for analysis. In suspected child abuse cases, a thorough police investigation is as essential as a thorough home assessment or medical examination.

SECTION VI. RESOURCES FOR CHILD CARE PROFESSIONALS

Chapter 18: Drawings in Abuse Cases

Drawing is a helpful tool in understanding the concerns and perceptions of a child who has been exposed to traumatic events. By encouraging and guiding an abused or traumatized child through drawing, a clinician can gain access into thoughts and feelings to enhance assessment and guide intervention. Simultaneously, the clinician can promote a normal trajectory of development, including the vital skills needed for relearning the world in light of the traumatic events that have occurred.

Chapter 19: Prevention NEW CHAPTER!

Programs involved in the prevention of child maltreatment are working to teach and support parents, equip children with personal safety and violence prevention skills, educate the public about abuse, advocate for policies and practices that support parents, and prevent teen pregnancies among a host of other strategies to prevent abuse. While early efforts were lacking in outcome data, there is now a growing body of data pointing to effective strategies for prevention that can be used in future efforts to prevent maltreatment.

Chapter 20: Resources and Settings NEW CHAPTER!